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Prospective drug utilization review (DUR) screening in most states will have to be conducted manually when the OBRA 1990 DUR requirements become effective Jan. 1, 1993, Oregon Pharmacy Programs Manager Lisa Huntsinger told NARD annual meeting attendees in Seattle on Oct. 28. Huntsinger, who implemented Oregon's retrospective DUR program in 1989 and will be responsible for making sure the state meets the new federal DUR requirements, noted that while "more and more" states are moving to "a paperless claims approach, many states are going to have to start out manually." She predicted that "most states" will eventually move "toward an electronic [claims and DUR] process where they can actually provide to [pharmacists] information on a state-wide basis." The Health Care Financing Administration was scheduled to publish the OBRA 1990 DUR regulations in the Nov. 2 Federal Register (see preceding story). Huntsinger said that "right now states are scrambling to implement" DUR. Asked whether state Medicaid programs will be required to provide electronic adjudication to monitor over-utilization, Huntsinger noted that the federal government currently does not require states to have electronic claims processing but does provide incentives for states to move toward electronic claims systems. "There are incentives under OBRA 1990 of 90% matched funds for states to put in electronic programs just dealing with adjudicating [pharmacist] claims -- not even including [drug utilization] screening," she observed. "Even so, because of limitations related to technology [and] time limitations, there are a lot of states that currently aren't taking advantage of" the federal incentives, Huntsinger said, "but states are now working towards that." She predicted "some states" will be ready for electronic claims processing in a "few months" while "other states...are looking at 10 years down the road." Oregon is preparing for the possibility that the federal government will take severe measures to enforce its new DUR requirements, Huntsinger indicated. "Some argue that [HCFA] would never take away the federal funding because that would kill the Medicaid program," she said; however, "there is nothing to stop the federal government from just wounding a state by sanctioning for several days for not meeting compliance." Huntsinger noted that HCFA already has audited Oregon's Medicaid drug price rebate program. The prospective DUR requirements will put a "heavy burden" on pharmacists to extract information from patients in states that have not yet adopted an electronic DUR system, Huntsinger said. She pointed out that the federal prospective DUR screening requirements include therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect dosage or duration, drug-allergy interactions and clinical misuse/abuse. "Oftentimes you are going to run into patients...who may not know exactly what their diagnoses are or who may not consider aspirin a drug," she predicted. "Under the requirements of drug- drug interactions come those OTC products, so you are going to have to do a lot more interaction than maybe what you are used to doing," she cautioned the independent pharmacy group. Under the law, pharmacists will have to make a "reasonable effort" to comply with the patient screening requirement, Huntsinger said, suggesting that pharmacists should err on the side of caution in defining "reasonable effort." She said she knows of no state that has defined the term. However, she noted, the regs will allow pharmacists to delegate to staff the offer to counsel patients and to take patient screening information, although the pharmacist will retain final responsibility. In addition, Huntsinger reported that mail-order pharmacies and those pharmacies that provide deliveries will have to make a toll-free telephone line available to Medicaid beneficiaries under the patient counseling requirements. Whether prescription refills will fall under the patient counseling requirements is being left up to the states by HCFA, she noted. Based on the DUR legislation currently active in the states, she said that the states are split on whether they will require patient counseling for refills.

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